Background and purpose: Several studies have underlined the
importance of supplying patients with proper advice for the management
of low back pain and this, as indicated in many guidelines, has become a
common aspect in the treatment of this pathology. With regards to proper
use, the term "advice" means all the information the patient
receives either verbally, in writing or through audio-visual or
electronic means during the course of his treatment. In literature,
however, there is a scarcity of research which investigates the means
with which these suggestions are supplied, the content of these
suggestions and the frequency with which they are supplied. The aim of
this review is to examine the evidences regarding the advice to patients
with low back pain, concentrating on the existing relationship between
their content and their frequency with clinical effectiveness
demonstrated.

The secondary aim of the review was to evaluate the efficacy of the
informative interventions in relation to the stages of low back pain
(acute, sub-acute and chronic), the influence of the advice during
follow-up check-ups, and the value of the results evaluation
instruments.

MATERIALS AND METHODS

The types of interventions within the randomised and controlled
studies (RCT) included in the review have been divided in 5 categories:

1. The indication to remain active as the only type of
intervention.

2. The indication to remain active as the main type within a back
school program in which suggestions were supplied regarding postural,
ergonomic aspects and functionality of the spine

3. The indication to remain active coupled with an exercise
program.

4. The indication to remain active as part of a program to
recuperate the function.

5. The indication to remain active together with other
interventions (mobilization, electrotherapy, and other passive
treatments).

With respect to frequency, four different types of procedures have
been found with which advice has been given:

1. all at once

2. during the entire therapeutic programme

3. during the entire therapeutic programme together with
supplementary information

4. during the entire therapeutic programme and at follow-up
check-ups (short, medium and long-term) considered singularly or
combined together.

The search terms used in the electronic data banks (MEDLINE-Biomed,
Amed, CINAHL, PsycInfo,COCHRANE, PUBMED) have been:
ACUTE/SUBACUTE/CHRONIC LOW BACK PAIN, ADVICE, EDUCATION, PHYSIOTHERAPY,
PHYSICAL THERAPY, INFORMATION, PAMPHLETS, BOOKLETS, CLINICAL TRIALS e
RANDOMISED CONTROLLED TRIALS. The results of these studies have been
classified, in compliance with the World Health Organization's
International Classification of Functioning, Disability and Health
indications, according to five dominions recommended by Deyo and
Bombardier: the specific functioning capacity of the spinal column, the
overall state of health, the pain, the occupational disability and the
satisfaction of the patient.

The methodological quality of the gathered RCTs has been evaluated
through both the QUOROM (Quality of Reporting of Meta-analyses) and
Cochrane Group Spinal column Review guidelines. This has permitted to
subdivide the studies, especially in relation to their internal
validity, into a table with four progressive values:

* very low methodological quality

* low methodological quality

* intermediate methodological quality

* high methodological quality

Only studies with intermediate and high methodological qualities
have been included in the review; the others have been excluded.

RESULTS

Of the 717 articles gathered, 56 RCTs have been determined suitable
for the review through close examination of criteria for their inclusion
or exclusion. Of the remaining 56 RCTs, only 39 have reached a level of
intermediate or high methodological quality and were included in the
study with this subdivision in relation to the phase of low back pain:
acute low back pain 13, sub-acute low back pain 7, chronic low back pain
19. The results, based on the different types of interventions, are as
follows:

* Indications in addition to exercise: this is the most utilized
type of intervention in the acute (62%) and chronic (42%) phase but is
not used in the sub-acute phase. It is the most effective in improving
pain, the function of the spine and the occupational disability in the
chronic phase but has not shown any increased efficacy with respect to
just remaining active in the acute phase.

* Indications as part of a back school: it was found to be the most
utilized in the sub-acute phase (37%--43%) and the most effective in
improving the function of the spinal column in this sub-group.

* 22 of 39 RCTs included (56%) have showed a positive effect of the
suggestion to remain active with respect to the control group. Sixteen
RCTs (41%) did not demonstrate any differences, and 1 (3%) unfavourable
results. The most studied intervention is that which advised to remain
active with respect to the general practitioner's traditional
treatment.

* Indications and phases of low back pain: a positive result of the
advice regarding the managing of acute low back pain was obtained in 15%
of the studies as opposed to 86% of the sub-acute phase and 74% of the
chronic phase. In this last phase the most researched experimental
intervention was to give indications together with exercise or with a
functional recovering programme.

* The influence of advice at the check-ups:positive results were
maintained in the group of patients in the sub-acute and chronic phase
but the methodology ofthe different studies are not comparable due to
the different duration of the followup and to the diverse procedures in
the administration of the indications at the different check-ups.

* Instruments used for the evaluation of the results: the
categories most utilized for the analysis of the results were: the
specific functionality of the spinal column (19), workplace disability
(18), and the frequency and intensity of the pain (17).

DISCUSSIONS AND CONCLUSIONS

This review sustains the current recommendations that the advice to
remain active is sufficient for acute low back pain while it is not in
the chronic phase where, to be able to promote an efficient
self-managing of the problem by the patient, it is necessary to add
either an exercise or a functional recovering programme. In the
sub-acute phase of low back pain the advice, coupled with a back school
or a programme to recuperate functionality with a behavioral cognitive
approach has shown positive effects, even in the long term. The results
of this review help track the directions in which future research should
go: investigate which content and frequency should have the indications
that are given to the patient; improve the quality of the RCTs that
study back pain in the sub-acute phase; promote more standardized back
school programmes so as to improve clinical research on their
effectiveness; testing the importance that is currently given to the
indications in follow-ups of patients with chronic back pain; using more
appropriate measurement systems based on the characteristics of the
patients' ailment.

COMMENTS

Some methodological limits, indicated by these same authors, are
recognizable in both the potential risks of "publication bias
", that is, the lack of research in the area of "grey
literature " (articles rejected because they do not demonstrate the
positive effects of experimental therapy, Degree or Master's
theses, convention speeches; etc.), generally of low value or use, and
the other--a little more important--is the lack of an evaluation method
on the size of the clinical effect of the results of the studies so that
the conclusions found are through the results obtained by considering
each study equal to another. A metanalysis has, therefore, not been
carried out. These limits in internal validity are, in my opinion,
compensated by the clinical relevance of the review and it is on a few
of its aspects that I would like to pause:

* The study uncovers the efficacy of the advice to remain active,
especially in patients with acute back pain. Given the heterogeneousness
ofback pain patients, the suggestion to remain active can assume even
more different significance in relation to factors such as age, type of
occupation, type of sports or recreational activity practiced, and other
concurrent pathologies. Generally, the suggestion is to be interpreted
as an urging to not completely reduce ones daily activities due to pain
since bed rest does not contribute towards the resolution ofthe
patient's clinical picture. Maintaining daily activity also assists
in preventing the onset ofthe bad practice ofavoiding movement which, as
we know, contributes to the low back pain's becoming chronic. To
give more significance to the suggestion of remaining active, a possible
research hypothesis can be to fine tune instruments to evaluate the
fitness of back pain sufferers, especially in relation to each
one's lifestyle.

* In the studies included in this review the content of the
indications given to the patients is varied: they go from the simple
advice of remaining active, to the educating programme of a back school
(which includes suggestions on posture, ergonomics, spinal column
anatomy and its functionality) all the way to cognitive behavioural
techniques aimed at reducing the patient's fear of moving as well
as checking his sickbehaviour. An analysis on the effectiveness of the
content in the indications given to patients has not been carried out,
therefore, it is not yet possible to know what exactly to communicate to
the patient to induce him to remain active. Since the patients with low
back pain are very diversified, maybe it is not useful to try to find
one universal remedy for everyone but, rather, coherent educational
approaches for each of the different clinical sub-groups (and a large
portion of low back pain research is moving towards the definition of
classification systems of patients in homogeneous groups). Even the
various methods of transmitting information (verbally, in writing or
through audio-visual or electronic means) have not been sufficiently
investigated so as to give complete certainty on the best instruments to
use and for this, too, research has ample room in which to move.

Dr. Pietro Scaglia

PT, OMT

Master in Manual Therapy and Musculoskeletal Rehabilitation

Board's Member of the Aifi's Group of interest in Manual
Therapy

S.D. Liddle *, J.H. Gracey *, G.D. Baxter **

* Health and Rehabilitation Sciences Research Institute, University
of Ulster, Northern Ireland ** Centre for Physiotherapy Research,
University of Otago, New Zealand